The advent of the American Psychiatric Association’s publication of its revised Diagnostic and Statistical Manual recently generated some discussion about the diagnosis of Major Depressive Disorder in a January 24th New York Times article.
Qualifying for the diagnosis involves feelings of sadness or emptiness, loss of interest in most daily activities, sleep disturbances, weight loss, fatigue, and distractibility, all or in part, to the extent of impairing functioning. In the DSM IV R that will be replaced by the DSM 5 (the new version uses Roman numerals) grieving the loss of a loved one was not seen as a sign of depressive disorder until at least two months following the loss, unless suicidal thoughts were present.
Paula Span, the author of the Times article, notes the opinion of an advisory committee to the Association for Death Education and Counseling that bereaved people “will receive antidepressant medication because it is cheaper and ‘easier’ to medicate than to be involved therapeutically.” In addition, it is pointed out, antidepressants have side effects.
Medicating depression can be very useful; research findings go in a few directions: medication and psychotherapy in combination is often more powerful than medication alone, both helping to lift the depressed feelings and empower the sufferer to deal with her life; psychotherapy alone can be as beneficial as medication, and long term psychotherapy has been shown to strengthen people for longer periods of time than short term therapy.
We know that depression can come from many sources. What underlies each is an experience of loss: loss of a relationship, loss of opportunity, loss of some aspect of physical health, and of course, death of a loved one. Psychotherapy may be useful in a variety of ways to help with depression: it provides both a place to put it, so to speak, and the care of a mental health professional who will help to validate the experience and sensitively encourage movement through the feeling. This element of the work of psychotherapy is enormously important, and reminds me of the comment a rabbi made to me at a family funeral in which he linked grieving and the 23rd Psalm together. He reflected that the profound lesson in the statement, “though I walk through the valley of the shadow of death…” is to be found in the image of walking through the valley. Painful awareness of loss needs to recede, and will, in time, as we continue to move forward.
Let’s say that the experience of loss in one case is not through death, but through job loss and difficulty finding new employment. The stress that this can impose on an individual and on her family is enormous. If her family is reasonably loving and sensitive, they will hold and support her; if they are more preoccupied with themselves, they may blame her for upsetting their lives. Job loss and continued frustration in finding new work can erode sleep, which is a crucial factor in producing feelings of well being and digesting stress. Sleep is necessary for recovery, so that we can go out the next day with some vigor to tackle the problems that are in front of us.
We know that the way we think influences the way we feel, and that mood affects behavior. In the case of prolonged frustration, such as the job loss scenario just described, it’s important to get a hold on what you’re thinking about yourself. It is not uncommon for people under this sort of stress to create a story in which they see themselves as not very good, incompetent, hopeless, etc. The “I’m just not good enough” story is sinister, and robs people of energy and optimism. In their recent NY Times article, Secret Ingredients for Success, January 19, 2013, Camille Sweeney and Josh Gosfield remark, “It’s easy to find pat ways to explain why the world has not adequately rewarded our efforts. But what we learned from conversation with high achievers is that challenging our assumptions, objectives, at times even our goals, may sometimes push us further than we thought possible.”
When we are depressed we go deeply into ourselves, in a sense providing holding for our distress, much as we would hold and comfort a distressed child. The experience can help us to know ourselves intimately; some people avoid depression by working compulsively, seeking highs through risky behavior, having sex compulsively, and through other behaviors that reflect a kind of running away from an important core part of themselves. The only thing that happens when we avoid the depression and the loss and perhaps anger that underlies it is that it waits for us un-chewed, un-swallowed and un–digested. In a similar vein, if we judge ourselves for being depressed or judge the depression itself as bad, the depressed feelings last longer. The following image, from Mindful Meditation practice, may be helpful:
“Let your eyes close. Take a few nice deep breaths from way down inside, and let the exhaled breath be longer than the inhaled breath as this will help to relax you more quickly and more deeply. Now see the pain of your depression, sadness, anger, or anxiety floating up to your mind’s eye in bubbles…make no effort to change the feelings, only observe them and let them float away…the depression bubble floats away, the sadness bubble floats away, the anger bubble floats away, as you give them no more importance than any other feeling….when you’re ready, open your eyes.” Allow perhaps ten minutes for this meditation.
This kind of work is essential to your healing. Again, if your child is distressed, and you are a caring parent, you won’t be impatient with her distress. You may hold her on your lap or in your heart, and be interested in all of her feelings. Your interest and care will provide the holding she needs to begin to let her feelings be alright, and as the distress ebbs away her emotional balance is restored. To take the analogy a little further, as her sniffling abates you might ask if she would like some ice cream.
This is the work of self regulation and as it is achieved, faith in oneself for being able to “process” bad feelings in this way becomes more solid. The process is embodied in Billy Holiday’s lyric “Good morning heartache, sit down.” Counterintuitively, we need to welcome the depressed feeling when it is there, be with it, feed it and put it to bed. This picture is that of a caring, tender parent, one that accepts and doesn’t judge what her child presents.
This practice of using acceptance as a strategy for problem solving in place of working hard on it runs counter to western ideology. Of course, when we’re depressed, our energy is depleted, and feeling tired is a predominant experience that frames how we think and what we do. Nevertheless, some tendency to harangue oneself with the ethic of working hard on the problem may float around one’s consciousness, and make itself known with such messages as, “if you would only…,” or, “pick yourself up…what’s the matter with you, anyway?”
It is as if some part of us regards depression as another problem that has to be solved, reflecting an attitude similar to that which is imposed on us, and which we impose on ourselves, in the workplace. In his NY Time article of 2/19/13, Relax! You’ll be More Productive, Tony Schwartz notes that “More, bigger, faster is the ethos of the market economies since the Industrial Revolution, and is grounded in a mythical and misguided assumption — that our resources are infinite.”
This is not to say that “pushing through” emotional distress has no place. Indeed, distraction, investment in activities that are productive or recreational are good strategies for overcoming bad feelings, and should be engaged in when the depressed mood lifts just enough. Ultimately, however, the best way to manage depression is by showing it tenderness and compassion. Gordon Marino, author of Try a Little Tenderness (NY Times 2/13/13) recognizes the resistance Americans commonly have to this recommendation: “To feel tenderly is to feel vulnerable and vulnerability is not a favorite American dish.” He also observes that “the ancient Greeks, who understood psychological matters in terms of the elements, believed that too much Spartan tough-guy training literally desiccated the soul, rendering it hard and insensitive. For them, tenderness would have involved a moistening of the psyche and an opening up to the impingement of the outer world.”
Creating a space inside for our suffering with an attitude of interest, respect and tenderness enables us to listen to what it is telling us and to foster the work of healing. Avoiding doing this only makes the pain last longer.